Cramps In the Elite Tennis Player In the Heat: An Algorithm for Success Wesley Troyer, DO Emory Sports Medicine Fellow @WesTroyerDO
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Cramps In the Elite Tennis Player In the Heat: An Algorithm for
SuccessWesley Troyer, DO
Emory Sports Medicine Fellow@WesTroyerDO
18-year-old ranked junior tournament player cramps in the calves and hamstrings in his 5 match of a national tournament in July.
How do you approach the situation? Now? After the Match? For the future?
Exercise Associated Muscle Cramps (EAMC)
• Defined as painful, spasmodic, and involuntary contractions of the skeletal muscle occurring during or immediately after physical exercise or sports event 1
• Typically occur in exercising musculature but can be generalized in some athletes
• Can last for minutes to hours in length• Ranges from a mild inconvenience to debilitating
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Presentation Notes
Typically in biarticular muscles, such as hamstrings, quads, gastrocs.
Exercise Associate Muscle Cramps (EAMC)-It’s Complicated!
Muscle Fatigue?
Electrolyte Loss?
Dehydration?
Localized vs. Systemic?
Figure 1: “Exercise Associated Muscle Cramping Risk Factors and Proposed Mechanism” from manuscript submitted for publication, Troyer et al “Exercise Associated Muscle Cramps in the Tennis Player”
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First step in learning how to treat cramps starts with understanding what is causing them
Muscle Fatigue Drives Cramping
Figures from the following paper: Qiu J, Kang J. Exercise Associated Muscle Cramps -A Current Perspective. Scientific Page of Sports Medicine. 2017:3-14.
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We know that regarding exercise associated muscle cramps, as the muscle gets tired, it becomes more cramp prone. This is due to excitatory activity from the muscles increases leading to contraction, while those inhibitory fibers that cause relaxation of the muscle decreases. Creates this cramping prone state where contraction increases the excitatory transmission and becomes difficuly to stop
Heat Cramps?
No single association between heat and development of EAMC4
EAMC likely to occur from a combination of factors.
Muscle cramps can occur in cool conditions1,2
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Presentation Notes
While the cramps we are talking about today do tend to be increased with increased temperature, they are not what is defined “heat cramps” in some of the literature, which itself is really a misnomer.
Contributing Factors in Tennis
HIGH SWEAT RATES IN ATHLETES
TOURNAMENTS WITH MULTIPLE MATCHES A DAY
LONGER MATCHES ENVIRONMENT
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Presentation Notes
-Sweat rates in adolescent tennis players could be in excess of 1 L per hour and even greater sweat rates up to 2.5 L an hour in older adolescents was noted -Athletes can participate in multiple matches every day for several days which makes recovery/ nutrition intake more difficult -Time on the court without water breaks contributes to high sweat rates -Heat increase fatigue on the body, which contributes to cramps
How do we address cramping during match play?
Figure 2: “Proposed Flowchart for Treatment of Acute EAMC”from manuscript submitted for publication, Troyer et al. “Exercise
Associated Muscle Cramps in the Tennis Player”
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Presentation Notes
Passive Stretching is the most effective method to stop cramping the quickest! Massage of the affected muscles can also help. Decreasing intensity of play would help, but not always possible. This is why we see cramping in games more than practices. May be some evidence that low bolus of substances like like pickle juice, vinegar may help alleviate cramping faster than hydration with water alone and believed to act on chemoreceptors in the oropharynx. On the other hand, systemic cramping is harder to treat and less defined. Lower level evidence suggests adding 3gm of Sodium to a bottle of carb/electrolyte beverage to those athletes with increased sweat rates may be beneficial as well. Adding Na is key as water itself and most name brand electrolyte beverages are hypoosmolar and will actually cause dilution of those levels within the bloodstream.
What about when it becomes a recurrent issue?
Evaluation by Physician and Basic Labs (CMP/ Electrolytes)
Cramp Journal
Rule out other causes of cramping
If recurrent despite work-up, consider EMG/ Muscle Biopsy or reevaluation of diagnosis.
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Presentation Notes
Labs may indicate underlying medical issue or cause for concern and lead to more extensive work up. While Potassium and Magnesium depletion have not been found to alter cramp threshold. In studies of triathletes, long distance runners, when comparing the electrolytes numbers of crampers and non crampers post race, they were comparable. If normal, having athlete track nutrition, hydration intake, sleep patterns, hours played, external stressors may help identify causes for concern that may contribute to development of cramps. Many of these don’t allow muscles to optimize use of energy and develop premature fatigue. If initial labs were abnormal or concern for certain conditions based off additional symptoms, may warrant more extensive workup and history. What medications/ supplements is the athlete taking. Is there concern for metabolic disorders, DM2, Vascular or Thyroid Disorders, or neurologic processes that could be confused with cramping such as radiculopathies or myopathy.
Strategies and Prevention
Carbohydrate intake of 6-10 g.kg -1 d-1 and protein intake of 1.6g·kg-1·d-1 for those training 4-6 days a week. 6
Drink at least one Liter of water or electrolyte beverage one-hour prior or maintaining proper hydration.
Train at increased levels of intensity and duration.Warm up prior to competition.
Acclimatize to current environment conditions.Wear light-colored, breathable clothing.
BeforeMatch
https://unsplash.com/photos/sI-p_NLBNr0
Strategies and Prevention
Recommend 30-60g.hr -1 of carbohydrate during match-play that lasts longer than 2 hours, as has been linked to improved performance 6
Drink 200ml (<27°C) – 400ml (>27°C) of water or sports beverage at change over to maintain hydration.7,8
Consider 0.5 tsp of NaCl to 16oz sports drink if early signs of systemic cramping. 7,9
Stretch or massage affected musculature if early signs of EAMC during breaks and in between points. 10-12
Sit in the shade or use an ice towel to cool affected musculature.
DuringMatch
https://www.dailymail.co.uk/sport/tennis/article-1284023/Andre-Agassi-Anna-Kournikova-voted-sexiest-tennis-players-time.html
Strategies and Prevention
Carbohydrate intake of 1.5 g.kg -1 after matches when glycogen synthesis is highest tofacilitate repletion 6
Start rehydrating immediately post match with goals of 125-150% of estimated losses within 4-6 hours
Cool down and stretching program post match
Change out of wet, damp clothes and get into cool environment.
AfterMatch
https://www.pinterest.com/pin/4292562127965276/?autologin=true
Take Away Points!• Stay prepared by packing appropriate clothing, maintaining suggested nutrition, and proper
hydration prior to match play, especially in conditions that can hasten muscle fatigue.
• Be able to recognize the signs and symptoms of EAMC and treat appropriately depending on the athlete’s situation.
• If an athlete develops recurrent, systemic muscle cramping that is refractory to the above interventions, consider further work up for possible other causes.
• If any concerns for hemodynamic instability, AMS, or concerns for heat stroke Change treatment plan and Treat immediately/transport.
References1. Schwellnus MP, Drew N, Collins M. Muscle cramping in athletes--risk factors, clinical assessment, and management. Clin Sports Med. 2008;27(1):183-94, ix-x.
2. Qiu J, Kang J. Exercise Associated Muscle Cramps -A Current Perspective. Scientific Page of Sports Medicine. 2017:3-14.
3. Schwellnus MP, Derman EW, Noakes TD. Aetiology of skeletal muscle ‘cramps’ during exercise: a novel hypothesis. J Sports than usual exercise intensity were the only indepen- Sci 1997; 15: 277-85
4. Maughan, R. J. (1986) Exercise-induced muscle cramp: a prospective biochemical study in marathon runners. J Sports Sci, 4, 31-4.
5. Jones B, Rock P, Smith L, et al. Medical complaints after a marathon run in cool weather. Phys Sportsmed. 1985;13:103-110.
6. Ranchordas MK, Rogersion D, Ruddock A, Killer SC, Winter EM. Nutrition for tennis: practical recommendations. J Sports Sci Med. 2013;12(2):211-24.
7. Bergeron MF. Heat cramps during tennis: a case report. Int J Sport Nutr. 1996;6(1):62-8.
8. Kovacs MS. Hydration and temperature in tennis - a practical review. J Sports Sci Med. 2006;5(1):1-9.
9. Bergeron MF. Heat cramps: fluid and electrolyte challenges during tennis in the heat. J Sci Med Sport. 2003;6(1):19-27.
10. Bertolasi L, De Grandis D, Bongiovanni LG, Zanette GP, Gasperini M. The influence of muscular lengthening on cramps. Ann. Neurol.; 1993. p. 176–80.
11. Eaton JM. Is this really a muscle cramp? Postgrad Med. 1989;86(3):227-32.
12. Helin P. Physiotherapy and electromyography in muscle cramp. Br J Sports Med. 1985;19(4):230-1.
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